Provider First Line Business Practice Location Address:
124 COMMODORE ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRATT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67124-2994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-508-6025
Provider Business Practice Location Address Fax Number:
620-508-6415
Provider Enumeration Date:
09/14/2006